Provider Demographics
NPI:1003051020
Name:LAZADERM SKIN CARE CENTRE PC
Entity Type:Organization
Organization Name:LAZADERM SKIN CARE CENTRE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORNELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:605-275-6128
Mailing Address - Street 1:PO BOX 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-335-1952
Mailing Address - Fax:605-373-9971
Practice Address - Street 1:5011 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2268
Practice Address - Country:US
Practice Address - Phone:605-275-6128
Practice Address - Fax:605-373-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDDO9926OtherRAILROAD MEDICARE
SDS102981Medicare PIN